CONCLUSIONES Y RECOMENDACIONES

Introduction

The use and efficacy of cognitive behaviour therapy (CBT) in the treatment of primary major depressive disorders is now well established on both sides of the Atlantic (e.g. Rush et al. 1977; Blackburn et al. 1981). More recently, its use in anxiety disorders has been similarly well described (Beck et al. 1985). The use of CBT in the treatment of depression or anxiety that arises as a secondary consequence of physical illness has been less extensively researched. A small number of studies have been published in the literature pointing to the possible use of CBT in patients with multiple sclerosis (Larcombe and Wilson 1984), epilepsy (Tan and Bruni 1986), and irritable bowel syndrome (Schwarz and Blanchard 1986), as well as with those suffering from painful conditions such as rheumatoid arthritis (Bradley 1985), or coping with the consequences of coronary surgery (Valliant and Leith 1986) or myocardial infarction (Stern et al. 1984). The sample sizes were small; the applications of CBT varied between group, individual, and telephone sessions; the outcomes were variable, with evidence of both success and failure. These modest results may dampen some therapists’ enthusiasm for trying CBT with physically ill patients, but the studies quoted so far can only be regarded as a preliminary attempt to ‘test the water’. Few of the reports gave details of the problems of applying CBT to these patients and relatively little information is available on if, or how, the CBT approach was modified to tackle the specific needs of this group.

One of the most interesting potential applications of CBT to the physically ill is its use with cancer patients. Again there is a small, but growing, literature. Maguire and colleagues (1985) in the UK, and Worden (1987) and colleagues in the USA, have provided some preliminary studies in this area. The early results suggest that CBT can be an effective therapy for cancer patients, used either alone or in combination with antidepressant drugs. These groups of researchers also made preliminary attempts to identify factors that made some cancer sufferers more vulnerable to emotional disorders.

In this chapter I will briefly review the prevalance of psychological morbidity in cancer patients and outline why CBT may have a role to play in such disorders. In addition, I will describe some of the specifie issues that need to be addressed in applying CBT to this patient population and try to identify potential problem areas. A case study of the use of CBT in a female patient with breast cancer will be described to highlight some of the strategies that may be used.

Prevalence of psychological problems in cancer patients

The diagnosis of cancer represents a major and catastrophic life event to most individuals (McIntosh 1974). As Massie and Holland (1984) point out, an individual’s ability to adapt depends on the threat it poses to their ‘age-appropriate’ goals (e.g. family, career); their prior level of emotional adjustment; the presence of a social support network; and disease-related factors such as the site of the tumour, the presence of disabling symptoms, treatment variables, and prognosis. The commonest emotional response of any individual to the diagnosis of cancer follows the classical sequence of a crisis reaction: initial shock and disbelief are followed by anxiety, anger, guilt, and depression. The period of adjustment is variable, but the acute reaction usually begins to resolve over 7–14 days. In some cases, this adaptation may be considerably delayed or may never occur, whilst in others the illness is denied.

In a significant number of individuals the emotional response takes the form of a depressive or anxiety disorder. At least 25 per cent of post-mastectomy patients develop these disorders in the twelve to eighteen months following surgery (Morris 1979). A similar figure is reported for patients with a colostomy following treatment for bowel cancer (Devlin et al. 1971). Exacerbations of these symptoms may occur with evidence of recurrence of the cancer (Silberfarb et al. 1980), or at the end of the course of radiotherapy (Holland et al. 1979). Psychiatric morbidity may also be a direct consequence of specific chemotherapy regimes (Hughson et al. 1980).

Estimating the prevalence of psychiatric disorders in the physically ill is often problematic, but there is well-documented evidence that the actual level of morbidity in an oncology unit greatly exceeds that recognised by the staff caring for the

patients (e.g. Levine et al. 1978). This lack of detection may be a function of the patients’ reluctance to reveal their fears or the staff’s failure to respond to verbal and non-verbal cues. Unfortunately, even when anxiety or depressive disorders are recognised they frequently remain untreated. Greer (1985) suggests that the staff tend to regard these conditions as an understandable response and so fail to consider that psychiatric help is either feasible or indicated.

The lack of adequate recognition and treatment of the emotional consequences of cancer is disappointing for two reasons. First, over the last decade there has been a rapid expansion in the physical therapies available to treat a wide variety of cancers. The survival times for many patients have been significantly lengthened, although some of the treatments are themselves difficult to tolerate. These factors have led to an increasing awareness of the need to maintain the quality of life experienced by the patient. It is no longer merely a question of being ‘grateful to be alive’. Second, there is evidence that the psychological response to the cancer may affect the length of survival. Several studies (e.g. Greer et al. 1979) indicate that the outcome at 5 years is better in those patients who either deny the existence of the illness or show a ‘fighting spirit’, shorter survival rates being associated with stoic acceptance or a helpless-hopeless response.

There are some data available on which individuals are most vulnerable to psychological problems. First, with regard to physical status, patients most at risk of psychological problems are those who undergo mutilating surgery (Dean et al. 1983), those with inadequately controlled pain, those in poorer physical health generally, and those with advanced stage illness (Holland et al. 1983). Patients who fail to cope with radiotherapy show ‘extremes of behaviour’ (e.g. withdrawal), engage poorly with health professionals, and have unrealistic expectations about their prognosis (Schmale et al. 1982). Poor psychosocial adjustment after mastectomy is associated with premorbid neurotic traits (Schonfield 1972), lack of close personal relationships (Weisman and Worden 1977), lack of employment (Bloom 1982), and a history of previous psychiatric disorder (Morris 1979). Weisman and Worden (1977) have also identified a group of poorly coping patients with a wide variety of different tumours. They found that ‘poor copers’ showed a long history of inadequate problem solving in a variety of situations.

Why use cognitive behaviour therapy?

Maguire and co-workers (1985) have often advocated the use of antidepressant or anxiolytic drugs in patients with cancer. They feel that there has been a reluctance to prescribe psychotrophic drugs because of the obvious ‘reactive’ nature of the psychological problems. In many instances the severity of the symptoms and the type of illness do warrant drug therapy. In other instances, pharmacotherapy is required in order to enable the patient to engage in counselling and support. However, the use of drugs in cancer patients presents a number of difficulties that may realistically make people wish to avoid prescribing them:

1. The patient’s psychological symptoms may not fit neatly into the pattern of a particular syndrome and may not show features that would be resolved by drug therapy. Often the presentation is a mixture of anxiety and depressive symptoms, frequently coming under the rubric of DSM III-R ‘adjustment disorder’ (American Psychiatric Association 1987). CBT may tackle the combination of problems presented in a more comprehensive way than pharmacological treatment.

2. Even when drugs seem to be indicated, patients with cancer are frequently more sensitive to their side-effects. This is particularly true of tricyclic antidepressants; cancer patients are less tolerant of the anticholinergic side-effects, possibly due to changes in hepatic enzyme activity (Massie and Holland 1984).

3. Antidepressant drugs may be contra-indicated because of interactions with other physical treatments. Monoamine oxidase inhibitors should not be combined with opiate analgesics. Tricyclic antidepressants are contra-indicated with the chemotherapeutic agent procarbazine (Massie and Holland 1984).

4. The risk of a suicide attempt may be high in a depressant and hopeless patient. Psychotropics may merely provide the patient with the means to carry this out.

5. It is important to consider the ‘message’ being given to patients and their families. With CBT, the statement being put forward focuses on helping the individual to participate actively in the development of coping strategies. Drug therapies make the patient the passive recipient of a ‘cure’. The patients’ preferences also become important here. Do they have more faith in pharmacology or do they prefer a psychological approach?

If pharmacotherapy is used, it should be seen as an adjunct to rather than a replacement for psychological treatment. However, as Worden (1987) points out, whilst there is a vast array of psychosocial interventions available for cancer patients, most are aimed at helping them and their families cope with dying. CBT differs from many of these therapies because it attempts to enable the patient to adjust to the problems of living. The focus is on controlling the quality of life in a situation where the ‘quantity’ may be an unpredictable variable. This is not to suggest that CBT should replace other psychological interventions. The use of counselling and supportive psychotherapies is generally known to be beneficiai (e.g. Bloom et al. 1978). However, it is interesting to note that some of the most effective programmes tend to incorporate many techniques that would come

within the classic CBT framework. Sobel and Worden (1980) focused on problem-solving skills, whilst Gordon et al. (1980) utilised a programme of supportive therapy with education and information giving and environmental manipulation. This aimed to give patients a more realistic outlook, increase their daily activities, and improve their adjustment to the disorder.

Specific issues in applying cognitive behaviour therapy to cancer patients

The following section refers to specifie issues that may need to be tackled in a course of CBT with a cancer patient who is suffering from psychological problems. It is obvious that some of these difficulties may also be experienced by patients with other physical illnesses.

Grieving for the ‘lost self’

One of the major problems confronting the patient will be the effect of the illness on their self-esteem and self-image. The role of the individual in the family and work situation may change significantly. Self-esteem will be affected by loss or changes in role. Cancer sufferers often feel stigmatised by colleagues and friends. Those close to them often feel uncomfortable in the patient’s company, not knowing if they are or are not allowed to discuss the illness.

The disfigurement brought about by surgery can have a tremendous effect on the individual’s self-image. Many women report sexual difficulties following mastectomy related to their anxieties about their body image (Morris 1979). These difficulties are often compounded by a sense of personal failure and self-blame that the individual has developed cancer in the first instance.

In many ways the patient’s view of themselves is tackled in the same way as it would be in CBT in general (e.g. see Beck et al. 1979; Williams 1984). In addition the following points should be remembered:

1. With the physically ill, subjective perceptions of personal worth and degree of handicap may be distorted, but in tackling these issues there is also a need for a realistic appraisal of the patient’s role and help is needed in adjusting to actual changes that may be required.

2. It is often important to involve the spouse in discussions about self-image in patients who have undergone disfiguring surgery.

3. Role-plays can be used to enable the patient to take the lead in interactions with friends and colleagues. This allows the patient to take control of discussions about the illness and its treatment.

Locus of control

Patients frequently feel hopeless because of the overwhelming sense of lack of personal control over their illness and prognosis. This sense of powerlessness is very demoralising. At some point a sensitive exploration of the patient’s fears about coping with death is necessary. The patient can be helped in several ways:

1. An acknowledgement that the future is uncertain, accompanied by the provision of clear information about what is and is not known about their particular illness.

2. According to Gomez (1987), most patients’ fantasies about their death include images of ‘disastrous dyscontrol’ and an agonising, often painful and lonely end. It is important to take on these anxieties and to talk in detail about all aspects of concern. Additional meetings can be organised with the clinicians to discuss pain control, etc.

3. Avoiding overgeneralisation of feelings of lack of control by getting the patient to define those aspects of life that they are in control of and those which no one can control.

4. Helping the patient overcome any guilt or anger they feel about their lack of control. Physical status

There may be realistic limitations placed on the patient because of physical disability or side-effects of treatment. This needs to be taken into account when planning activity schedules by:

1. planning activities that require less exertion or mobility;

2. using activities that enhance residual abilities rather than expose deficits;

3. putting limitations on what the patient is allowed to tackle at a given time, e.g. in the initial time after radiotherapy (which can be particularly tiring) only allowing the individual to choose from a specific number of activities that have been preselected as feasible for someone in that physical state.

Pain

For some patients the control of pain is a major problem. There is a fairly extensive literature available on the application of CBT techniques to control pain (e.g. Pearce and Richardson 1987). As well as ensuring that adequate physical treatment is being employed, additional strategies include the following.

1. The use of a pain diary to monitor fluctuations in intensity and duration and allow any factors that reduce the pain to be identified.

2. Examination of pain-related cognitions. 3. Distraction techniques.

4. As with physical disability the pain may limit the patient’s ability to engage in particular activities. The intensity of the pain may be ‘coded’ by the patient, e.g. using a ‘colour coding’: pain of medium severity equals orange, more severe pain equals green, etc. Activities are similarly coded depending on difficulty in accomplishing them with a particular level of pain. The patient then chooses activities from the list according to the colour coding. This often avoids disappointment and anger at not being able to achieve or enjoy a specific activity at any time and engenders some feelings of control, e.g. a male cancer patient enjoyed golf, but had a metastatic lesion in his spine. He coded severe pain as green and moderate pain as orange. Nine holes of golf were coded as orange and eighteen holes as green. He overcame some of his frustration by avoiding attempting too much and got positive reinforcement from successful outings.

Treatment issues

The patient may wish to discuss their radiotherapy or chemotherapy treatment, as the side-effects of these can be very distressing. Some may wish to stop treatment entirely. In addition, issues of long-term hospitalisation or moving into a hospice may need to be tackled. The following strategies may be helpful:

1. Examining the pros and cons of continuing treatment; this includes issues such as the quality of life, prognosis without treatment, and effects on significant others. Collaboration with treating physicians and family is vital.

2. Generating alternative solutions with regard to whether to accept hospice or other care and discussing the timing of any moves that may be desired or become necessary.

Longstanding deficits in coping strategies

Many patients who fail to cope with cancer show longstanding deficits in coping strategies (Worden 1987). It was found by Weisman and Worden (1977) that ‘poor copers’ showed two main deficits in their coping repertoire. First, they tended to over-use strategies that were least effective in resolving problems e.g. drinking as a means of avoidance of issues. Second, they were unable to generate alternative coping strategies. These deficiencies were accompanied by high levels of emotional distress.

‘Good copers’ not only generated more alternatives, but were more effective at evaluating and rank ordering the potential solutions to a variety of problem situations. Hopefully, it is obvious from this description that standard CBT interventions could be used to deal with ‘poor copers’.

Specific problems in applying cognitive behaviour therapy in cancer patients

There are many potential pitfalls in trying to apply CBT to cancer patients. Perhaps one of the most important is simply that for many patients their negative view of reality is not a distortion but an accurate reflection of the problems they are facing. This does not preclude the use of CBT, but it must be acknowledged. The therapist must not attempt to make the patient into an unrealistic optimist, nor should they identify with the patient’s hopelessness to the extent that they cannot function effectively. Other problems that may need addressing are the following:

1. The prevalence of organic brain syndromes in cancer patients is estimated to be about 40 per cent (Levine et al. 1978). It should be borne in mind that the patient may have or may develop subtle cognitive deficits that impair their ability to engage in CBT. In some instances these problems can be overcome by modelling task assignments within the sessions and ‘overlearning’, as described by Hibbard et al. (1987) in their work with brain-damaged patients.

2. Co-operation with other health care professionals. A vital feature of CBT in physically ill patients is its role in giving information about the disorder and discussing the patient’s views about the treatment options available. Close collaboration is required with other members of staff to ensure consistency in these communications.

3. The patient’s family or significant others may want or need to be involved. This has many potential benefits in reinforcing the therapist’s work. It can also afford an opportunity to examine the family’s cognitions and emotional responses to the illness.

4. If the patient is a medical or psychiatric in-patient, CBT may need to be adapted to take this into account. These problems have been discussed by Blackburn (this volume) and Scott (1988).

Finally, it is important to remember that in a significant subgroup of cancer sufferers, denial is an adaptive coping strategy that may be associated with longer survival times (Greer et al. 1979). In some patients, denial may reduce the individual’s sense of hopelessness and so it should not automatically be challenged.

Case study

Margaret was a 37-year-old female who was referred by a hospital social worker to a specialist centre for CBT. Margaret was a widow who worked as a shop assistant and lived with her 15-year-old daughter. She had recently had a partial mastectomy with breast reconstruction, followed by a course of radiotherapy. When that treatment came to an end she was seen by the social worker who felt she was suffering from ‘stress and depression’. A psychiatric assessment revealed that the patient was suffering from major depression without melancholia, accompanied by symptoms of generalised anxiety disorder. Her past history revealed three previous episodes of major depression over the past 12 years that had all been precipitated by stressful life events. Margaret’s mother (who lived several hundred miles away), appeared to have a longstanding untreated paranoid psychosis.

At the ‘intake’ interview, an assessment was made to determine if CBT might be a suitable approach to Margaret’s problems. This interview was carried out by an experienced cognitive therapist (who then allocated the patient to the most appropriate